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OFFICE OF
INSPECTOR GENERAL
QUESTIONABLE BILLING
FOR MEDICAID PEDIATRIC
DENTAL SERVICES
IN LOUISIANA
Suzanne Murrin
Deputy Inspector General for
Evaluation and Inspections
August 2014
OEI-02-14-00120
TABLE OF CONTENTS
Objective ......................................................................................................1
Background ..................................................................................................1
Methodology ................................................................................................4
Findings........................................................................................................7
Appendix ....................................................................................................... 15
Acknowledgments .........................................................................................17
OBJECTIVE
To identify dental providers with questionable billing for Medicaid
pediatric dental services in Louisiana in 2012.
BACKGROUND
Medicaid is the primary source of dental coverage for children in
low-income families and provides access to dental care for approximately
37 million children.1,2 Medicaids Early and Periodic Screening,
Diagnostic, and Treatment (EPSDT) benefit requires States to cover all
medically necessary dental services for children 18 years of age and
under.3 Medicaid dental services must include diagnostic and preventive
services, as well as needed treatment and followup care. Diagnostic
services may include x-rays of the mouth; preventive services may include
cleanings, topical fluoride applications, and dental sealants. Dental
treatment covers a wide range of services such as fillings; tooth
extractions; and pulpotomies, which are often referred to as baby root
canals.
In recent years, a number of individual dental providers and chains have
been prosecuted for providing services that were medically unnecessary or
that failed to meet professionally recognized standards of care. These
providers have often been found to have suspect Medicaid billing patterns
when compared to their peers. For example, FORBA Holdings, LLC
(FORBA), a dental management company that manages clinics nationwide
known as Small Smiles Centers, settled with the United States in 2010
for $24 million to resolve allegations of providing services that were either
medically unnecessary or performed in a manner that failed to meet
professionally recognized standards of care to children with Medicaid.4
As part of the settlement, FORBA agreed to enter into a 5-year Corporate
Integrity Agreement with the Office of Inspector General (OIG). FORBA
subsequently changed its name to Church Street Health Management,
LLC, and was then acquired by CSHM, LLC.
Thomas P. Wall, Dental Medicaid 2012, American Dental Association (ADA), 2012.
Centers for Medicare & Medicaid Services (CMS), Annual EPSDT Participation
Report, Form CMS-416 (National), Fiscal Year 2012, April 3, 2014.
3
Social Security Act (SSA) 1905(r)(3); 42 CFR 441.56. Dental services are covered
up to age 18, but States may choose to extend eligibility through age 21. Louisiana is
among the States that have done so.
4
U.S. Department of Justice (DOJ), National Dental Management Company Pays
U.S. Senate Committee on Finance and Committee on the Judiciary, Joint Staff Report
on the Corporate Practice of Dentistry in the Medicaid Program, page 10. Accessed at
6
The exclusion is effective September 30, 2014. OIG, OIG Excludes Pediatric Dental
7
In addition to CSHM, the Senate Finance and Judiciary Committees investigated the
following chains: Kool Smiles, ReachOut Healthcare America, Heartland Dental Care,
and Aspen Dental Management. In addition, other dental chains have also been the
subject of Federal and State investigations. For example, in 2012, the All Smiles chain
and its owner agreed to pay the United States and State of Texas $1.2 million to resolve
allegations that they violated the civil False Claims Act and the Texas Medicaid Fraud
Prevention Act. DOJ, Texas Orthodontic Clinic and Former Owner Resolve Allegations
http://www.justice.gov/usao/txn/PressRelease/2012/MAR2012/mar21Malouf_AllSmiles_
Settlement_PR.html on June 13, 2014.
OIG, Questionable Billing for Medicaid Pediatric Dental Services in New York,
OEI-02-12-00330, March 2014.
9
OIG, New York Improperly Claimed Medicaid Reimbursement for Orthodontic Services
the need for continuing care and did not ensure that services were
adequately documented.
METHODOLOGY
We based our analysis on Medicaid paid dental claims provided by
Louisiana with service dates from January 1, 2012, through December 31,
2012. We excluded claims for services with special payment rates, such as
those submitted by Federally Qualified Health Centers; State and local
agencies; and facilities operated by university dental-school clinics.10 We
analyzed claims from rendering dental providersthe providers who
provided the services, as opposed to billing providersto ensure that we
compared claims from the providers who performed the services.
We focused our analysis on general dentists and oral surgeons. We
analyzed the two provider types separately because their billing patterns
varied significantly. We did not include pediatric dental specialists
because the wide variation in their billing behavior made it difficult to
analyze them as one peer group. Some pediatric dental specialists provide
services that make them similar to general dentists, while others provide
more complex services. In addition, we did not do a separate analysis of
orthodontists or endodontists because there were too few to analyze.11
General Dentists
Our analysis focused on 512 general dentists who provided services to
50 or more children with Medicaid during 2012.12 These dentists served a
total of 316,955 children with Medicaid. We developed a number of
measures to identify dentists with questionable billing who are extreme
outliers when compared to their peers. We developed these measures
based on input from officials from CMS, The American Academy of
Pediatric Dentistry, and The American Dental Association. We also
discussed these measuresas well as the States oversight of Medicaid
pediatric dental claimswith staff from the State Medicaid agency, i.e.,
the Louisiana Department of Health and Hospitals. We developed these
measures to capture several different types of fraud, waste, and abuse. For
these measures, we included only the children with Medicaid served by
these dental providers; we did not include other children whom they
served.
10
We also excluded services provided in a hospital setting because these services differ
greatly from services provided in an office setting. In total, we identified 840 dental
providers who provided services to children with Medicaid in 2012 on a fee-for-service
basis.
11
Only seven orthodontists and three endodontists received payment for services in 2012.
12
A total of 704 general dentists provided services to children with Medicaid in 2012.
For each general dentist, we calculated the following three measures for
2012:
fillings,
extractions,
pulpotomies.
For each measure, we analyzed the averages and the distribution for all
general dentists.
Next, we set a threshold for each measure that, if exceeded, indicated that
the dentist had billed an extremely high amount or number compared to
other general dentists in the State. We used a standard technique for
identifying outliers, known as the Tukey method.13 Under the Tukey
method, outliers are values greater than the 75th percentile plus 1.5 times
the interquartile range. Additionally, under this method, extreme outliers
are values greater than the 75th percentile plus 3 times the interquartile
range. For this study, we employed this more conservative approach to
identify extreme outliers. We considered dentists who exceeded one or
more of these thresholds to have questionable billing.
Oral Surgeons
Unlike general dentists, who provide a variety of services, oral surgeons
typically perform a more complex set of procedures. For this analysis, we
analyzed 41 oral surgeons who provided services to 50 or more children
with Medicaid in 2012.14 These oral surgeons served a total of
8,358 children with Medicaid.
For this analysis, we calculated three measures for each oral surgeon:
13
14
As with our analysis for general dentists, for each of these measures, we
set the thresholds for extreme outliers at the 75th percentile plus 3 times
the interquartile range. Oral surgeons who exceeded these thresholds were
extreme outliers compared to their peers and were considered to have
questionable billing.
Additional Analysis
For each general dentist or oral surgeon who exceeded one or more of the
thresholds, we conducted Internet searches on the providers background
and analyzed his or her claims and payment history. In a few cases, we
excluded dentists or oral surgeons who were actually specialists but had
not indicated this on their claims. For the remaining providers, we
determined which providers worked for a dental chain in 2012, based on
the billing names associated with their claims.15 Finally, we researched
public records available on LexisNexis and from the Louisiana State
licensing board to determine whether the providers had ever been
sanctioned by the board.
Limitations
We designed this study to identify general dentists and oral surgeons who
warrant further scrutiny. None of the measures we analyzed confirm that a
particular provider is engaging in fraudulent or abusive practices. Some
providers may be billing extremely large amounts or numbers for
legitimate reasons.
Standards
This study was conducted in accordance with the Quality Standards for
Inspection and Evaluation issued by the Council of the Inspectors General
on Integrity and Efficiency.
15
FINDINGS
Twenty-six general dentists and one oral surgeon in
Louisiana had questionable billing in 2012
We identified 26 general dentists and 1 oral surgeon with questionable
billing.16 We identified these providers by looking at general dentists and
oral surgeons in Louisiana who served more than 50 children with
Medicaid in 2012.
The providers with questionable billing are extreme outliers when
compared to their peers. They make up 5 percent of the general dentists
and oral surgeons we reviewed, and they provided care to 9 percent of the
children with Medicaid served by the providers we reviewed.17 Medicaid
paid these 27 providers $12.4 million for pediatric dental services in 2012.
Almost a third of the providers with questionable billing worked for two
dental chains. In addition, four of the providers with questionable billing
had previously been sanctioned by the State Board of Dentistry.
These billing patterns indicate that certain dental providers may be billing
for services that are not medically necessary or were never provided.
They also raise concerns about quality of care and whether children
treated by these providers were harmed by these procedures. Although
some of their billing may be legitimate, providers who bill for extremely
large numbers of services warrant further scrutiny.
Six General Dentists Received Extremely High Payments Per
Child
General dentists in Louisiana received an average payment of $264 for
each child with Medicaid. Six dentists, however, received more than two
times this amount, or an average of more than $700 per child.18 These
dentists received more than $2,000 per child for a total of 237 children.
One of these dentists received more than $8,000 for services provided to
one child over the course of three visits. Extremely high payments raise
concerns about whether these dentists are billing for unnecessary services
or services that they did not provide. See Table 1 for more information on
16
Measure
Threshold of
Questionable
Billing
Number of Dentists
Who Exceeded
Threshold
$663
27
134
10
* Includes general dentists who served 50 or more children with Medicaid in 2012.
Measure
Proportion of children
who received pulpotomies
Proportion of children
who received extractions
Proportion of children
who received stainless
steel crowns
Proportion of children
who received fillings
Threshold of
Questionable
Billing
Number of Dentists
Who Exceeded
Threshold
3%
13%
11%
36%
6%
26%
33%
91%
* Includes general dentists who served 50 or more children with Medicaid in 2012.
10
raise concerns both about potential fraudulent billing and about quality of
care and childrens safety.
Almost a Third of the Providers With Questionable Billing
Worked for Two Dental Chains
Of the 27 dental providers with questionable billing, 8 worked for 2 dental
chains. A concentration of dental providers with questionable billing in
chains raises concerns that these chains may be encouraging their
providers to perform unnecessary procedures to increase profits.
Four of the eight providers worked for a chain that operates mobile
school-based clinics around the country. This chain has been the subject
of investigations arising from complaints that dentists affiliated with it had
treated children without their parents permission and had provided
medically unnecessary services.20 The Senate Finance and Judiciary
Committees also investigated this chain, citing a potential pattern of
treatment without parental consent. 21 For example, according to the
Committees report, a 4-year-old medically fragile boy in Arizona was
treated without a parents consent, receiving pulpotomies and stainless
steel crowns while being physically restrained by three staff
members. Subsequent examinations initiated by the family suggested that
the dental work provided was unnecessary.
Another four providers worked for a Louisiana-based chain. All four
providers performed extractions on an extremely high proportion of the
children with Medicaid that they served. In addition, two of these
providers received extremely high payments per child.
Four of the Providers With Questionable Billing Had Actions
Taken Against Them by the State Board of Dentistry
Two of the general dentists with questionable billing had previously been
subject to disciplinary action by the Louisiana Board of Dentistry. The
Board initiated disciplinary action against one dentist for illegally or
illegitimately prescribing, dispensing, or administering habit-forming or
other legally controlled substances, as well as failing to maintain accurate
logs of controlled substances. The Board initiated disciplinary action
against the other dentist for failing to provide access to treatment records.
20
11
Additionally, two other dentists had received violations from the Board for
advertising that included fraudulent, false, deceptive, or misleading
content.
12
13
chains. The State should also ensure that it is appropriately authorizing services
prior to payment. Further, as the State transitions to managed care, it should
continue to collect detailed data that will allow it to conduct proactive data
analysis. The State should also ensure that managed care entities employ
adequate safeguards to monitor dental providers. Such monitoring can result in
cost savings, as well as ensuring that children receive quality dental care.
Take appropriate action on the dental providers identified as having
questionable billing
In a separate memorandum, we will refer to the State the dental providers whom
we identified as having questionable billing. The State should review these
providers billing patterns; review dental records and supporting documentation;
and/or perform unannounced site visits. Then the State should determine what
action(s) are most appropriate. These actions include, but are not limited to
(1) law enforcement actions, if fraud is identified; (2) referral to the States board
of dentistry for licensure violations; (3) recoupment of payments, if the State
determines that claims were paid in error; (4) revocation of Medicaid billing
privileges; (5) education about how to appropriately bill for pediatric dental
services; and (6) no action, if the State determines that a given provider does not
demonstrate a vulnerability to the program or to children with Medicaid.
14
15
APPENDIX
Agency Comments
16
APPENDIX A
Ritchie, Brian P.
July 24,2014
Page 2
/S/
J. Ruth Kennedy
Medicaid Director
JRK/JK
c: Michael Breland
Mary Johnson
John Korduner
Jeff Reynolds
Bill Root
17
ACKNOWLEDGMENTS
This report was prepared under the direction of Jodi Nudelman, Regional
Inspector General for Evaluation and Inspections in the New York regional office,
and Nancy Harrison and Meridith Seife, Deputy Regional Inspectors General.
Lucia Fort and Judy Kellis served as the team leaders for this study. Central
office staff who provided support include Clarence Arnold, Meghan Kearns, and
Christine Moritz.
18
Office of Investigations
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations
of fraud and misconduct related to HHS programs, operations, and beneficiaries. With
investigators working in all 50 States and the District of Columbia, OI utilizes its resources
by actively coordinating with the Department of Justice and other Federal, State, and local
law enforcement authorities. The investigative efforts of OI often lead to criminal
convictions, administrative sanctions, and/or civil monetary penalties.